Moral hygieneCulture and Society Jeffrey A. Schaler Recent years have witnessed the expansion of also pursue a lawbreaker to apprehend him and purportedly "public health" programs into punish him. These actions of defense or punish- areas of personal conduct not traditionally viewed ment are not considered medical treatment.
as medical. Since sickness and health are meta- People who have studied medicine have no spe- phors readily applicable to any human activity, we cial competence to pronounce in these areas, should be alert to the possibility that the rheto- though just like anyone else, they are entitled to ric of "public health" may be employed to legiti- declare their opinions as citizens and voters.
mate the intrusion of governmental or privatebureaucratic power into individuals' private lives.
This issue of conceptual demarcation arises most We may, of course, use a medical metaphor to acutely when people are "treated" without their describe such matters. Anything that is undesir- consent, on the grounds that their behavior may able may be called an illness, and any response to constitute a menace to public health.
it may be called a treatment. Thus, crime may be There are normally three situations in which an "illness" and more police or longer sentences medical treatment is administered without a may be proposed "treatments." But this is just a person's consent: A person may be treated with- metaphor, a way of speaking, like saying we are out consent when he is literally unconscious, be- sitting on top of the world or have butterf lies in cause then he literally does not have the cogni- our tummy. Crime is not literally illness and law tive capacity to comprehend the consequences enforcement is not literally medical treatment.
of refusing treatment. A person can be treated Nevertheless, metaphor can be a formidable without consent when he is literally a child, or weapon when employed to persuade and to po- due to brain damage is mentally a child, because liticize. Today, metaphor is increasingly used to then he literally does not have the developmen- extend the boundaries of public health. Treatment tal capacity to comprehend the consequences of without consent is necessary, we are now con- refusing treatment. And a person may be treated tinually being told, when a person is metaphori- without consent when he is literally contagious cally unconscious—he "lacks insight" into his dis- with disease, because then he could, by infecting eased behavior; when a person is metaphorically other people, cause harm to them without their a child—there is a "threat to self," meaning that he does not act in what some psychiatrist sup- According to the traditional view, these three poses is his best interest; and when a person is cases of nonconsensual treatment are appropri- metaphorically contagious—he is a "threat to ate to a political order in which power is circum- others," for example, if those others copy his drug- scribed to protect individual rights: they are situ- taking, or are outraged by it.
ations where physicians, qua physicians, may treat When policy-makers begin to swallow the no- people without their consent.
tion that deliberate behavior can be a treatable It has also been held that there are quite dis- disease, they are being led to take the metaphori- tinct non-medical grounds for doing things to cal for the literal. Treatment becomes paternalis- people without their consent. If someone wants tic and rationalized in the name of protecting a to cause harm to others we may act in self-de- person from himself, and others from him. Pro- fense, or to protect potential victims, and we may tecting people from themselves does seem to be the raison d'être of the emerging ideology of should go after the purveyors of tobacco or alco- public health.
hol. Not so today.
In a parallel with Dr. Himmler's "racial hygiene" Opponents of the persecution of the tobacco (the term Rassenhygiene was coined by Alfred and alcoholic beverage industries often remark Ploetz), today's new public health ideology can that we might as well prohibit the sale of high-fat be ch arac ter ized a s mo ral hygiene— or high-carbohydrate foods. This seems ridiculous moralischehygiene. Both are forms of medical and today, but how will it seem 30 years in the fu- public health imperialism. The rhetoric of moral ture? If we take a look at what the government hygiene certainly recalls Robert N. Proctor's de- has done to tobacco, we may hesitate to buy stock scription of the philosophical dimension of the in companies which make potato chips or soda.
"leader principle" (Führerprinzip), in which The point at issue is not whether smoking, health care (Gesundheitsfürsorge) was replaced drinking, eating potato chips, or drinking soda are by health leadership (Gesundheitsführung), and good or bad, but who decides what the individual curative medicine (Fürsorge) by preventive medi- can put in his mouth: the individual or the gov- cine (Vorsorge). Moral hygiene seeks to bring all ernment? Is it obvious nonsense to say that people human activity within the domain of medicine and who eat potato chips can't stop? Of course it is, public health. Human beings are again being ho- but it is just as obvious nonsense to say that mogenized by the state, in a manner reminiscent people who smoke cigarettes can't stop. It is just of National Socialist Gleichschaltung. It goes with- as obvious nonsense to say that people who drink out saying that the old racial hygiene and the new beer or snort cocaine can't stop. Some of them moral hygiene have many differences; what they won't stop, just as some folks won't stop watch- have in common is that they provide a legitimiz- ing baseball or going to church. That's their choice.
ing formula, based on an extension of the medi- At bottom, I think everyone understands this. We cal metaphor, to sanctify physical coercion of in- all know that such behaviors are matters of vol- dividuals who behave in ways that powerful untary choice, and that some people, given lib- people dislike.
erty, will make foolish choices. But the metaphor The ideology of moral hygiene extends the of moral hygiene is bewitching.
imperial boundaries of public health in two ways.
Speaking strictly and literally, disease is a physi- The first is by viewing all health matters as "pub- cal malfunction of the body. Ethical or prudential lic health" concerns, even if they are purely de- mistakes in judgment are not literally diseases.
rived from voluntary human behavior. The second Ethics is a branch of philosophy, not of medicine.
is by applying a medical metaphor to every sphere Medicine is, of course, thoroughly intertwined of life, and then, quite absurdly, taking the meta- with ethical problems in practice. But ethical phor literally.
problems are not medical problems. Behavioral An example of the first is the allegation that a choices can affect one's chances of getting a dis- slight increase in the rate of genetic damage arises ease, but no ethical choice is in itself a disease.
from smoking marijuana. This becomes a supposed Cirrhosis of the liver is a disease caused by justification for viewing the voluntary pastime of habitual heavy drinking. Habitual heavy drinking smoking marijuana as somehow a medical mat- is not a disease. Habitual heavy drinking does not ter. Examples of the second would be compulsive become a disease by being called "alcoholism." shopping, compulsive gambling, compulsive sex, Similarly, a broken neck is (in the broadest but or addiction to the Internet, all treated by some still literal sense) an illness, but hang-gliding is mental health professionals as examples of "men- not an illness, and hang-gliding would not become tal illness" and therefore public health problems.
a disease by being called suspendere labi.
One of the signs of this conceptual expansion- ism is that over time the preposterous comes to be taken quite seriously. What once seemed hi- By "behavior" I mean action subject to con- larious is now earnestly debated. Thirty years ago, scious control. It may be thoughtless or habitual, advocates of drug legalization would often remark but it still qualifies as behavior if the person can that we might as well persecute producers or change it by conscious decision. A person may consumers of cigarettes or beer. Everyone under- walk along without giving a thought to the way stood that this was pure irony, and that it was his legs are moving, but if for any reason he pays absolutely fatuous to suggest that the government attention to the movement of his legs, he can 64 SOCIETY MAY / JUNE 2002 modify his walking behavior, to avoid stepping in and vice versa. The more liberty people possess, puddles, for instance. Some bodily phenomena are the more responsible they must be for the conse- not under conscious control. Reflexes or seizures quences of their behaviors. The more responsibil- are not behavior, in this sense of the word, be- ity people are given—at work, for example—the cause the individual cannot control them or bring more they are at liberty to make policy decisions.
them on at will.
When responsibility decreases, liberty decreases.
This clear distinction was made long ago by Children are held to a lower standard of respon- Max Weber, who employed the term "action" for sibility than adults. Their liberty is restricted ac- what is here called "behavior." Weber pointed out cordingly. A prisoner in a penitentiary is deprived that the existence of borderline examples does of liberty. His room and board are provided by not nullify the difference in principle. Behavior is the state: he is not responsible for providing these always meaningful to the person behaving and is himself. This is why some people prefer to live in always a matter of choice.
prison: They do not want to be responsible for To be sure, behaviors have consequences: the their room, board, and general welfare. In effect, consequences of certain behaviors may enhance they do not want to be responsible for themselves.
health, aggravate existing diseases, or increase the The price they pay for irresponsibility is loss of likelihood of contracting some diseases. Much of what we do, however, may not affect our state of Those intent on medicalizing behavior often health and illness as much as we might like to claim that liberty and responsibility are negatively think. There is such anxiety these days about correlated: They contend that a person can expe- health matters that people tend to over-rate the rience greater freedom by abdicating responsibil- extent to which they can influence their health ity. For example, smokers who refuse to take re- and longevity. It is existentially comforting to sponsibility for the consequ ences of their think that we are more in control of our physical behaviors and blame tobacco corporations and health and the onset of disease than we actually nicotine for their smoking addiction, are led to are. Many people do everything "right" and still believe by anti-tobacco crusaders that they can get a disease. Many people do everything "wrong" experience greater freedom by surrendering per- and live long and full lives. With the majority of sonal responsibility. In this case freedom theoreti- diseases, the best thing we can do by way of pre- cally comes through monetary awards.
vention is to choose parents with the right ge- We cannot increase liberty by diminishing per- netic endowments.
sonal responsibility. When people are taught that In the older conception, public health was tac- they're not responsible for their behaviors, some- itly contrasted with private health. An epidemic one, or something, is scapegoated or blamed for of influenza was considered a public health prob- the unpleasantness and suffering they experience.
lem; an epidemic of recreational cycling was not Responsibility is assigned somewhere else. For considered a matter of public health. The strained example, drugs and drug dealers are scapegoated muscles, scratches, bruises, and occasional broken for the drug users' own behavior. Tobacco com- bones or concussion, results of the cycling craze panies and cigarettes are scapegoated for smok- in the late nineteenth century, were understood ers' own behavior. Scapegoating makes people feel to be among the health consequences of private better about themselves. It's a way of boosting behavior. The fact that private behavior can be self-esteem, expelling evil, and affirming the domi- aggregated statistically did not automatically make it a matter of public health. True, public healthdid concern itself with such areas as the diet of Persons and Things the poor, but it sought to improve these areas by Public health policies and practices were origi- educating poor people and enhancing their liv- nally based on a triad of specified components: ing standards, rather than, for example, by coer- host, agent, and environment. The host referred cively regulating the diet of all people below a to a person, a member of the community. The certain level of income.
agent usually referred to a living organism—aparasite, bacterium, or virus. Public health poli- cies based on this model were and are generally Liberty and responsibility are positively corre- successful in controlling, if not eradicating, pub- lated. If liberty increases, responsibility increases, lic health threats in the form of literal disease.
Today, however, the person-host component in ucts. The drugs are said to be dangerous and ad- this model is misconstrued as if it were a non- dicting. The person is misconstrued in people's living agent, a thing, and the agent component is minds as a thing: Behavior is discussed as if it were misconstrued as if it were a person, a moral agent.
a seizure, a neurological reflex. Drugs allegedly People are misinterpreted as things and things are addict the person. The person is done to by drugs.
misinterpreted as persons. This perversion of the A person is not regarded as an actor, a moral agent.
original public health model is an integral part of A chemical substance is viewed as an active, in- the increasingly prevalent practice of medicalizing tentional force in the world, while the consumer behavior. Violence, crime, suicide, illiteracy, guns, of that substance is viewed as an insensate ob- drugs, depression, over-eating, under-eating, under- ject incapable of resistance.
exercising, buying too much in shopping malls, No substance, such as heroin, cigarettes, alco- or having too many sexual partners, are all viewed hol, cocaine, or marijuana, can addict a person.
as "public health problems." People choose to addict themselves to substances.
Medicalizing behavior is also used in an attempt Yet the inversion of reality is part and parcel of to evade personal responsibility for the conse- the moral hygiene ideology. Where ordinary mor- quences of one's behavior. When responsibility is tals like you and I see a drunk resolutely assault- theoretically removed, it is frequently assigned or ing a helpless bottle of Skyy vodka, the ayatollahs attributed to something or someone else––a thing, of today's moral hygiene see a bottle of Skyy vodka another person, or the environment. When people resolutely assaulting a helpless alcoholic.
attribute responsibility for their behavior to ad-diction, drugs, mental illness, or a bad environ- ment, paternalism is rationalized, legitimized, and Just because moral hygiene views persons as justified by powerful others.
helpless things and inanimate substances as ma- One group of adults asserts that it knows what lign or beneficent persons, it should not be sup- is best for another group of adults. For example, posed that this ideology absolves all persons of adults who choose not to ingest hallucinogenic any blame. Far from it! The people who manufac- drugs assert that they know what is best for adults ture and sell these personified substances are vili- who choose to ingest these substances. The fied and demonized relentlessly.
former group deprives the latter of liberty, if they It is surely significant that the people who talk are powerful enough to do so. Similarly, people as if drug consumers cannot control their own who don't want to ingest select serotonin re-up- behavior always assume that drug dealers or to- take inhibitors such as Prozac, Paxil, or Zoloft, or bacco executives can control their own behav- anti-psychotic drugs such as Thorazine, Zyprexa, ior. In this way of thinking, moral responsibility is or Haldol, are coerced into ingesting them by an- displaced. If a person smokes, it is not his respon- other group of adults (usually psychiatrists, men- sibility but the tobacco companies' responsibil- tal health professionals, and family members). The ity. It may be worth exploring the hypothesis that former group is deprived of liberty by the latter.
this has something to do with the fact that to- Confusing and coercive messages are commu- bacco companies may be looted for millions of nicated to children in the name of medicine and dollars by ethically unfastidious lawyers, whereas public health: On the one hand children are told ordinary smokers may not.
by adults that they shouldn't ingest the drugs they The smoker is a helpless victim, but tobacco want to ingest to change the way they feel and executives are never considered helpless victims.
experience the world, for example, marijuana, al- The smoker cannot control his actions, but to- cohol, and hallucinogens. On the other hand, chil- bacco executives can control both their own ac- dren are told by adults that they should ingest tions and—magically—the actions of smokers. The the drugs they don't want to ingest, to change smoker cannot be held morally or legally account- the way they feel and experience the world, such able for his decision to smoke, but the tobacco as Ritalin, Prozac, and Paxil. All of this is done in companies must be held morally and legally ac- the name of public health, though in point of fact countable, not merely for their decision to pro- it has little to do with public health.
duce and sell cigarettes, but for consumers' deci- Consider how moral agency is attributed to sions to smoke. Evidently, ordinary consumers are non-living substances such as marijuana, cocaine, subhuman zombies, since they lack the capacity heroin, or LSD, and the nicotine in tobacco prod- for autonomous choice, whereas company execu- 66 SOCIETY MAY / JUNE 2002 tives and Colombian cartel leaders are authenti- The ideology of moral hygiene not only views cally human, though desperately wicked, and must health as the supreme value, but also views moral therefore be punished if they cause the hapless behavior as "healthy" or "sick." The result is to es- subhumans to injure themselves.
tablish the medical profession as a priestly caste, The view stated here, that behavior is a matter empowered by the state with the capacity to in- of choice, should not be confused with any par- tervene coercively in our lives. The literalized meta- ticular theory of what causes behaviors like drug phor of healthy behavior means that no area of our addictions. This view does not pretend to offer lives is protected against forcible intrusion by the an illuminating new explanation for why people government. Thus the Bill of Rights, almost in its choose to addict themselves to drugs, religions, entirety, is thrown in the trash. That this is no ex- sports, hobbies, life partners, or political ideolo- aggeration can be seen immediately by looking at gies. Doubtless they do so for many different rea- the day-to-day implementation of the "war on drugs." sons, arising out of their multifarious struggles tofind meaning in their lives.
"Harm Reduction" Movement Whenever there is an established church there are sectarian struggles within the church to get It is often assumed that we have an obligation the benefits of state endorsement for the views to be healthy, that bodily health is an important of each particular sect. The apostles of "harm re- value, if not the supreme value. In place of the duction" do not challenge the establishment of old idea that cleanliness is next to godliness, the the church itself: they differ over which kinds of contemporary view is that radical cleanliness— drug-related behavior are most harmful, and over the exclusion of all noxious substances—is god- whether doctors or policemen should be the en- liness. This modish view contradicts the recorded forcers. They therefore want to legalize various pronouncement of Jesus Christ that what goes drugs under a doctor's prescription, and to replace into the body does not defile a person: only what compulsory treatment by jail with compulsory comes out of the body—words and deeds—can treatment by psychotherapy.
defile a person. While it would go beyond the Proponents of harm reduction defend drug use scope of this article to discuss the correctness of on pseudo-medical grounds, and only under the the currently fashionable view, the crucial point control of physicians or public health profession- is that this view is not in the least a medical view- als. They argue that people who "abuse" drugs point, but entirely religious, in the broad sense of should be "treated" instead of "punished." They having to do with our ultimate value choices.
uphold the fallacies of moral hygiene, notably that Medicine can sometimes tell us what to do if any voluntary behavior with health effects is a we want to be as healthy as possible, but medi- medical matter and that voluntary behavior is it- cine cannot tell us that we ought to want to be as self healthy or sick, and can be treated.
healthy as possible. If a doctor advises a patient Treatment means psychotherapy, and psycho- to behave in a certain way, the doctor tacitly as- therapy means talking to people, in an attempt to sumes that the patient values his health highly persuade them to live their lives according to the enough to modify his behavior. The patient may, views of the psychotherapist. Jailing people for however, be fully prepared to sacrifice his health taking drugs is an outrageous invasion of their rather than change the way he lives his life. This rights, but at least it is honest brutality and hon- decision of the patient's is, quite literally, none of est repression. At least we know roughly what is the doctor's business.
going on: someone is being picked on because The doctrine that we are obligated to become some powerful people don't like the way he as healthy as we can is a religious one: it relates chooses to live his own life. By contrast, having to our highest values. If there is religious liberty, licensed agents of the state paid by the taxpayer however, then individuals are perfectly entitled to talk that person into a different ethical and re- to sacrifice their health to other values. It follows ligious outlook, all under the rubric of public that if the government promotes an ideology health, is a sickening perversion of both medicine which preaches that physical health is the su- and politics, and there is no telling what hell it preme value, we have here an "establishment of might take us to.
religion," as prohibited in the First Amendment to Increasingly, people horrified by the violence the United States Constitution.
and brutality of the war on drugs are calling for more emphasis on "treatment," but there are seri- so from a criminal justice point of view. In just ous problems with any such approach. First, ad- the same way, if a man looks at pornography and diction cannot literally be treated since it is not then commits rape, he should be prosecuted for literally a disease. Second, what passes as treat- the rape and not for looking at pornography, or if ment for addiction is indoctrination with a par- he reads the Book of Revelation and becomes a ticular worldview. The state has no business be- serial killer, he should be prosecuted for murder, ing entangled in this. Third, there is no need not for reading the Bible.
for any money to be appropriated by the state The hubris of moral hygiene can be seen as it for addiction "treatment," as the best form of moves into the arena of tobacco regulation. Indi- help for people who want help with addiction viduals who voluntarily choose a legal pastime problems is self-help groups, which are free and find themselves both persecuted as deviants and organized by people who want to help them- rewarded as victims. A smoker in California was selves. Finally, there is plenty of research to show awarded $3 billion for the consequences of his that professional addiction "treatment" is com- own behavior. The jurors' decision was based on pletely ineffective. The great majority of drug ad- the untruth perpetuated by anti-tobacco crusad- dicts cease, after a while, to be addicted—they ers that this man couldn't stop smoking.
"mature out" of their addiction—regardless of Tobacco companies are also accused of trick- whether or not they have been "treated" (I docu- ing smokers into being addicted to nicotine. (If it ment this and other relevant claims in Addiction really were nicotine to which they were addicted, Is a Choice).
they could simply take nicotine pills and not in-crease their risk of getting lung cancer.) This l Approach to Drug Addictio scapegoating on the part of anti-tobacco crusad- Although it would be best if the government ers absolves smokers of responsibility for the con- called off the "war on drugs," this conclusion does sequences of their actions, deprives people of the not follow simply from the view argued here, that right to smoke, and soaks the tobacco companies addiction is a choice. There are honest arguments (therefore ultimately future consumers of ciga- for state paternalism, and even for totalitarianism, rettes) of money—all in the name of public health which are beyond the scope of the present dis- and compassion. It has the effect of encouraging cussion. What is important here is to point out pervasive irresponsibility, because individuals that, under the banner of moral hygiene, coercion come to suppose that if anything bad happens to for moral and religious motives is dressed up as them as a consequence of their own actions, some- coercion for public health reasons.
one or something else is to blame.
Some people believe that it is right to use the Anti-tobacco crusaders defend themselves by police, the army, the FBI, the prisons—all the tax- claiming that the tobacco companies have tried funded agencies of coercion—to compel people to hush up the health dangers of smoking, though to live morally. Because this is at odds with Ameri- this would be pretty pointless if people were ac- can classical liberal traditions of individual respon- tually incapable of quitting the habit. Ever since sibility as ref lected in the Bill of Rights, it is a tobacco became familiar to the Europeans who kind of euphemism or rhetorical equivocation to explored America, folklore has warned of its health pretend that people who take drugs have no dangers. As soon as scientific evidence appeared choice in the matter—a fiction which most people that there possibly were real health risks, these instinctively understand to be a fiction, but which were publicly debated. Since the early 1950s, the muddies the waters sufficiently to distract atten- media have been filled with references to the tion from the irrationality, cruelty, and negation possible health hazards of smoking.
of liberty inherent in any "war on drugs." We accept as a fact that life is difficult: Grow- The fundamental case for repealing drug pro- ing up is difficult, going to school is difficult, go- hibition in its entirety is that people have a right ing to work is difficult, being married and raising to take whatever drugs they please. People should a family is difficult—all of this not to mention the be free to purchase, sell, and use any drug they numerous and diverse tragedies, illnesses, acci- want. If they harm themselves in the process, dents, and loss, we all face and in most cases sur- that's the risk they take. If they harm someone vive. But here, when it comes to a smoker, he theo- else in the process, without that person's consent, retically cannot give up his precious cigarettes they should be held fully accountable for doing because he is addicted. He cannot resist his temp- 68 SOCIETY MAY / JUNE 2002 tation and deprive himself of his temporary plea- public health, but a matter of morality or, in the sure because it is too difficult to do so.
broad sense, religion.
There is nothing scientific or medical about the claim that people cannot stop smoking. All therelevant research fails to corroborate, and much SUGGESTED FURTHER READINGS of it controverts, the theory that addicts suffer"loss of control" disabling them from rationally Chafetz, M. The Tyranny of Experts: Blowing the monitoring their drug intake. The continuing claim Whistle on the Cult of Expertise. Lanham, MD: that addicts cannot stop is, in Popperian terms, Madison Books, 1996.
untestable and therefore metaphysical.
Hayek, F.A. The Road to Serfdom. Chicago: The Univer- Drug prohibition and anti-tobacco legislation sity of Chicago Press, 1994.
are attempts to control peoples' behavior, instruct- Proctor, R.N. Racial Hygiene: Medicine Under the ing them how to live their lives because the gov- Nazis. Cambridge, MA: Harvard University Press, ernment knows best. The same is true for the form of indoctrination known as addiction treatment.
Schaler, J.A. Addiction Is a Choice. Chicago: Open Court Drug consumers can halt or moderate their drug intake when it becomes important enough for Szasz, T.S. Pharmacracy: Medicine and politics in them to do so. Addiction is not an involuntary ill- America. Westport, CT: Praeger, 2001.
ness; it is an attachment governed by choice, re-flecting the ways in which individuals find mean- Jeffrey A. Schaler, Ph.D., a psychologist, teaches at ing and value. Government interference with American University's School of Public Affairs and individuals' addictions is not strictly a matter of at Johns Hopkins University.
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Journal of Cancer Research Updates, 2013, 2, 000-000 1 Case Reports of Cancer Patients with Hepatic Metastases Treated by Standardized Plant Immunomodulatory Preparations Tibor Hajto1,* and Angelika Kirsch2 1Department of Immunology and Biotechnology, University Pecs, Faculty of Medicine, Pecs, Hungary 2Private Praxis, Paradiesstr. 14, Binningen CH-4102, Switzerland